Name _____________________________ Hire Date ____________

BU ID # _____________________________

EPPR.6

NEW STAFF PAPERWORK CHECKLIST Welcome to Baylor University!

Enclosed is confidential paperwork for you to complete and bring with you on your first day. Please print one sided.

For office use: Form Description

ALL NEW REGULAR STAFF – Complete the following forms and submit to HR on 1st day of work: Request for Direct Deposit Form * Baylor’s primary means of payment.

Form W-4 * Allows Baylor to withhold correct federal income tax from your pay. (HR Review of Social Security Card – note exact name and number)

Payroll Deduction Authorization * This authorizes use of your ID card - For your convenience, use your ID card to purchase meals and other services on campus and have charges deducted from your pay.

Personnel Information Form Basic information to update the Baylor personnel database and provide access to the Baylor computer system.

Self Identification Survey (optional) Self-Identification for governmental records and reporting requirements for the Administration of Civil Rights Laws and Regulations.

ID Card and Parking Permit Form requires HR signature – Bring on first day.

I-9 with proper identification(List of acceptable documents can be foundhere – please bring documents on first day.)

Required by the office of Homeland Security to establish identity and work eligibility, protecting you from discrimination on the basis of national origin or citizenship status. Begin online form at www.baylor.edu/hr/I-9.

Memorandum of Understanding Please sign and turn in the Employer copy with this packet.

Please keep the Employee copy - Basic agreements you are making with the university regarding the nature of your employment.

Electronic Form W-2 Election (optional) Allows Baylor to provide an electronic copy of your W-2.

Rcvd by HR

EE Will Return

Prior University Work Experience Applicable for individuals who have worked previously as faculty or staff at a university or college. Service associated with earning a degree or certification, such as graduate, work study, or pre-doctoral, does not apply.

Transcript(s) (if applicable) If you have not submitted a copy of your transcripts, please bring a copy with you for your employment file. (Applies to positions requiring a college degree.)

ALL NEW REGULAR STAFF - The following form is for you to keep: Baylor Email, Bear ID Activation & DUO Information about your Bear ID, BU Email, DUO, Parking and ID

Card. Affordable Care Act Information regarding health insurance marketplace coverage

options and your health coverage. ALL NEW REGULAR STAFF – The following form will be provided on your 1st day of work

Signed Employment Application A copy of your submitted employment application will be provided for your signature.

OFFICE USE ONLY:

Initial Provide purple copies to Payroll Copy W-4, Direct Deposit and Payroll Authorization onto purple paper.

Initial Enter NewHire information into Banner.

Set Up New Direct Deposit Authorization

1. Log into BearWeb www.baylor.edu/bearweb2. Click on Employee3. Click on Pay Information4. Click on Update Direct Deposit Authorization

5. Enter the below information:• Routing number (see “Sample” below for location on a check)• Account number (must be the FULL account number not just the last 4 digits)

(DO NOT enter your debit card number here) • Account Type (choose Checking or Savings)• Amount or Percent (input the dollar amount or percentage to go to this account)

(If all of your check will be going here, input 100 percent)

*If setting up multiple accounts, the last account entered MUST be 100% (this means 100% of the remaining amount willgo into that account).

6. Click Save

2.

3.

4.

5.

6.

Contact the Payroll Office x2217 if your Bank Routing number is not accepted

EPPR.4 Revised 06/10/2019

PAYROLL DEDUCTION NOTIFICATION and AUTHORIZATION

PRINTED EMPLOYEE NAME: _______________________________________________

BAYLOR ID NUMBER: ____________________________________________________ {PLEASE INITIAL AND SIGN IN THE SPACES DESIGNATED BELOW.}

Baylor On-Campus Parking Baylor provides an on-campus parking benefit to employees at no charge. Employees who wish to park on campus must register their vehicle(s) and keep vehicle information current with Baylor Parking and Transportation Services.

Employees are responsible for abiding by university parking regulations. Parking violations may result in a citation with a monetary fine. Fines will be deducted from the employee’s pay only after an initial appeal process has been concluded. Please note the university provided on-campus parking benefit is considered a privilege that can be discontinued by the University.

For more information about campus parking, updating vehicle information and services available, review the Parking and Transportation Services website at www.baylor.edu/parking.

____I understand that I am responsible for abiding by university parking regulations and that a violation may result in a citation and fine which will be deducted from my pay, unless the citation is dismissed through a formal appeal process with Parking Services. I understand that parking enforcement may include a parking notice, multiple parking notices, vehicle immobilization (a "boot") and/or towing of the improperly parked vehicle.

____________________________________________ ______________ SIGNATURE DATE

Personnel Information Form (PIF)

Employment start date: Baylor ID Number:

Department name:

Name:

Last First Middle Preferred First Name

Home Address: Street/Box: ____________________________________________________________________

City: __________________ State: __________ Zip: ____________________

Home Phone: ( ) Cell Phone: ( ) Personal Email Address:

Birth Date: Marital Status: Single Married

Religious Affiliation: Baptist Other (Indicate affiliation):

Emergency Contact Information:

Name (Last, First): Relation to employee:

Phone: Home: Cell: Business:

Address:

(if different than employee home)

Street/Box:

City: State: Zip:

College Education:

Baylor Online Directory Information Release Setting:Check below to indicate which information you want published

BOTH home & campus address and phone number (Y) ONLY CAMPUS address & phone number (C) NO address or phone number published (N) **NOTE: settings may be changed later using your Bear

ID** Electronic submission of this form will serve as your agreement to have your directory information published.

All employees are expected to comply with the law, as well as the policies, procedures, and practices of Baylor. Employment policies, including the Drug-Free Workplace Policy and Title IX Policy, are made available to employees online (www.baylor.edu/bupp). The information provided may be changed by the university from time to time and without notice. It is the employee’s responsibility to review policies upon employment and annually, thereafter. Violation of any policy may result in disciplinary action up to and including dismissal.

Initial

Please return this form to: Human Resources – Office: Robinson Tower, Suite 200, Email: askHR@baylor.edu, Fax: 254-710-3819, or Mail: One Bear Place #97053, Waco, Texas 76798-7053.

INSTITUTION CITY/STATE DEGREE

EARNED

MAJOR START DATE

(MM/YYYY)

GRADUATION

DATE (MM/YYYY)

/ /

/ /

/ /

/ /

Voluntary Self-Identification

Baylor University is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. Completion of information below is voluntary.

Name: Baylor ID Number:

What is your Gender? Female Male I prefer not to answer.

Are you Hispanic or Latino?

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

Yes No I prefer not to answer.

Optional Race Category: (Check all that apply) If you have identified yourself as Hispanic or Latino, you are not required to select an additional category.

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

I prefer not to answer.

Please return this form to: Human Resources – Email: askHR@baylor.edu, Office: Robinson Tower, Suite 200, Fax: 254-710-3819, or Mail: One Bear Place #97053, Waco, Texas 76798-7053.

Voluntary Self-Identification of VeteransAs a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

• A “disabled veteran” is one of the following:o a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of

military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; oro a person who was discharged or released from active duty because of a service-connected disability.

• A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

• An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

• An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.

I BELONG TO THE FOLLOWING CLASSIFICATIONS OF PROTECTED VETERANS (CHOOSE ALL THAT APPLY):

DISABLED VETERAN ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN ARMED FORCES SERVICE MEDAL VETERAN RECENTLY SEPARATED VETERAN

- DATE OF DISCHARGE FROM ACTIVE DUTY:

I am a protected veteran, but I choose not to self-identify the classifications to which I belong. I am NOT a protected veteran. I prefer not to answer.

Name: Baylor ID Number:

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

A copy of the veterans’ affirmative action plan is available upon request by Human Resources, between 8:00am and 11:00 am Monday-Friday via email at askHR@baylor.edu or in person at Suite 200, Clifton Robinson Tower.

__________________________ __________________

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2020 Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness Deafness Cancer Diabetes Epilepsy

Autism Cerebral palsy HIV/AIDS Schizophrenia Muscular dystrophy

Bipolar disorder Major depression Multiple sclerosis (MS) Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

☐ YES, I HAVE A DISABILITY (or previously had a disability)

☐ NO, I DON’T HAVE A DISABILITY

☐ I DON’T WISH TO ANSWER

Your Name Today’s Date

i

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2020Page 2 of 2

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

PLEASE NOTE: The EMAIL button may not function in all web browsers. If you experience difficulty with

the email button, PLEASE SAVE OR PRINT IT and return to Human Resources.

Saved forms can be emailed to: askHR@baylor.edu or faxed to 254-710-3819.

Printed forms can be mailed to: Human Resources, One Bear Place #97053, Waco, TX 76798-7053

ID Card and Parking Permit Authorization

Please issue to: Baylor ID #:

Effective Date: Ending Date:

(for temporary staff/AX only)

ID Card(s) Classification:

Faculty / Executive Staff

Staff

Spouse

Retiree

Honorary Retiree

Auxiliary

Temporary Staff Replacement

Parking Only (skip step 1)

Step 1: Present this form to ID Card Production (located in Parking Services) on your first day of

employment. Please be prepared to show a photo ID and have your photo taken for your Baylor

ID card.

Step 2: If possible, please follow the online instructions for registering your vehicle before arrival:

visit http://www.baylor.edu/dps/index.php?id=873876 and click the ‘My Parking Account’ icon.

Parking permits are virtual and connected to your license plate number. It is important to keep

your license plate number updated in your parking account.

Parking Services and ID Card Production are located together on the 1st floor of the Speight Parking

Garage at 1521 S. 4th Street. Office hours are Monday through Thursday, 8:00 – 5:00, Friday 8:00 –

3:30.

Authorized by: _________________________________________ Date: ________________

(Human Resources Representative)

Please direct questions to Human Resources at (254) 710-2000.

EPPR.6

BAYLOR UNIVERSITY

MEMORANDUM OF UNDERSTANDING REGARDING NATURE OF EMPLOYMENT

OF NON-CONTRACT EMPLOYEES

Name: ____________________________________________________________________________

BU ID#: ___________________________________ Date Employed: ______________________

As an employee of Baylor University, I acknowledge and agree to the following:

My employment is at-will, and either the University or I may terminate employment at anytime. I will abide by the policies and procedures of Baylor University. I accept the salary and personnel benefits authorized for the position as indicated in the offer letter for the start

date above. I understand that Baylor uses direct deposit as its primary source of payment for all employees. I also certify to the best of my knowledge I am physically qualified to perform the tasks and responsibilities of the

position for which I am being employed. Upon separation from service or request, I will turn in to Human Resources my: ID card(s), credit card, keys,

uniforms, equipment, and any other property of the University that I have in my possession. I will return any library books in my possession to the appropriate library.

I understand that as a service to employees, purchases and other University services may be charged with my Baylor ID card and such charges will be deducted from my paycheck. I authorize Baylor to deduct from my paycheck any amount owed to the University such as fines, fees, outstanding travel advances, dining services, health center, outstanding checks, student loans, etc.

The University’s Employee Policies are located on the University’s webpage, and this is the University’s sole means of publishing its policies. Additionally I acknowledge that the policy manual does not form the basis of a contractual relationship between the University and me regarding termination or otherwise. I acknowledge the University’s prerogative of revising its policies and procedures at anytime without notice, and I agree to abide by and be governed by such versions.http://www.baylor.edu/BUPP

The unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance or othermind-altering substance is prohibited at Baylor University. A Baylor employee who violates this prohibition is subject to discipline by the University. Such discipline may include required participation in a drugrehabilitation program or termination from employment.

I am aware that Baylor University has workers’ compensation insurance coverage through AIG for my protection. Workers’ compensation information is posted in the lobby of Human Resources. For additional information about your workers’ compensation rights, please call 1-800-252-7031 or contact the nearestTexas Workers’ Compensation Commission Office or you may contact Human Resources at (254) 710-2000for more details.

I may elect to retain my common law right of action if, no later than 5 days after beginning employment, I will notify Baylor University in writing that I wish to retain my common law right to recover damages for personal injury. If I elect my common law right of action, I cannot obtain workers’ compensation or medical benefits if I am injured.

If the position is funded by grant money, I understand that my employment is at will and is also contingent on continued funding.

Employee’s Signature Date Human Resources Date

NOTE: Baylor University is an At-Will-Employer; therefore, either Baylor or the employee may terminateemployment at any time.

BAYLOR UNIVERSITY

MEMORANDUM OF UNDERSTANDING REGARDING NATURE OF EMPLOYMENT

OF NON-CONTRACT EMPLOYEES

Name: ____________________________________________________________________________

BU ID#: ___________________________________ Date Employed: ______________________

As an employee of Baylor University, I acknowledge and agree to the following:

My employment is at-will, and either the University or I may terminate employment at anytime. I will abide by the policies and procedures of Baylor University. I accept the salary and personnel benefits authorized for the position as indicated in the offer letter for the start

date above. I understand that Baylor uses direct deposit as its primary source of payment for all employees. I also certify to the best of my knowledge I am physically qualified to perform the tasks and responsibilities of the

position for which I am being employed. Upon separation from service or request, I will turn in to Human Resources my: ID card(s), credit card, keys,

uniforms, equipment, and any other property of the University that I have in my possession. I will return any library books in my possession to the appropriate library.

I understand that as a service to employees, purchases and other University services may be charged with my Baylor ID card and such charges will be deducted from my paycheck. I authorize Baylor to deduct from my paycheck any amount owed to the University such as fines, fees, outstanding travel advances, dining services, health center, outstanding checks, student loans, etc.

The University’s Employee Policies are located on the University’s webpage, and this is the University’s sole means of publishing its policies. Additionally I acknowledge that the policy manual does not form the basis of a contractual relationship between the University and me regarding termination or otherwise. I acknowledge the University’s prerogative of revising its policies and procedures at anytime without notice, and I agree to abide by and be governed by such versions.http://www.baylor.edu/BUPP

The unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance or othermind-altering substance is prohibited at Baylor University. A Baylor employee who violates this prohibition is subject to discipline by the University. Such discipline may include required participation in a drugrehabilitation program or termination from employment.

I am aware that Baylor University has workers’ compensation insurance coverage through AIG for my protection. Workers’ compensation information is posted in the lobby of Human Resources. For additional information about your workers’ compensation rights, please call 1-800-252-7031 or contact the nearestTexas Workers’ Compensation Commission Office or you may contact Human Resources at (254) 710-2000for more details.

I may elect to retain my common law right of action if, no later than 5 days after beginning employment, I will notify Baylor University in writing that I wish to retain my common law right to recover damages for personal injury. If I elect my common law right of action, I cannot obtain workers’ compensation or medical benefits if I am injured.

If the position is funded by grant money, I understand that my employment is at will and is also contingent on continued funding.

Employee’s Signature Date Human Resources Date

NOTE: Baylor University is an At-Will-Employer; therefore, either Baylor or the employee may terminateemployment at any time.

EPPR.4

BAYLOR UNIVERSITY AUTHORIZATION FOR ELECTRONIC FORM W-2

Benefits of Receiving Form W-2 Electronically

There are multiple benefits to receiving an electronic Form W-2:

Earlier access to the Form W-2. No possibility an employee's Form W-2 might be lost, stolen, delayed or misplaced by the U.S mail

service or by the employee, once received. Access is available at the same easy-to-use, secure website at which an employee can access his/her

wage and general account information.

Access can be attained even if the employee is not presently at his/her residence, for example, ifparticipating in a University foreign program

The format of the online Form W-2 allows an employee to quickly and easily download the includedinformation into most tax preparation software.

Multiple levels of security, including the employee's ID number and personally chosen PIN number,

protect all information within the Bearweb System.

Disclosure Notices

An employee who consents to receiving his/her Form W-2 online will not receive a paper copy of the W-2. If an employee does not consent, he/she will continue to receive a paper copy of the W-2.

An employee who chooses to receive his/her Form W-2 online can also receive a paper copy of the W-2

by contacting the Payroll Office at 710-2217 or Payroll_Office@baylor.edu. Request for a paper copy

does not withdraw the employee's consent for electronic delivery of future W-2 statements.

An employee who chooses to receive his/her Form W-2 online can change his/her mind and withdraw consent

to online delivery. An employee's withdrawal of consent will be effective on the date received and the Payroll

Office will confirm with the employee in writing or by e-mail the effective date of withdrawal of consent. If

consent is withdrawn, it will only be effective for those W-2 statements not yet issued. Consent may be

withdrawn by sending an e-mail or other written notice to the following:

Payroll Office One Bear Place#97042

Waco, TX 76798 Phone: 254-710-2217

E-mail: Payroll_Office@baylor.edu

Employees will promptly be notified if any contact information changes.

The provision of an employee's Form W-2 by electronic format will cease upon the individual's termination of

employment with Baylor University.

All employees should be aware that the Form W-2, even when provided electronically, must be attached to their

annual tax return, usually the Form 1040. If the W-2 is provided electronically, the employee should print the

FormW-2 and attach it to his/her tax return documents.

The Bearweb website and the employee's Form W-2 may be accessed by any Baylor computer that provides

login access to employees. The Form W-2 statements will remain on Bearweb for at least 5 years.

Consent to Receive Your Form W-2 in Electronic Format in Lieu of Paper Format

I elect to receive my Form W-2 electronically until such time as I revoke my consent.

Name: __________________________________________ Baylor ID #: ________________

Signature: ____________________________________________ Date: ___________________

Baylor University Retirement Income Plan Prior University Work Experience Certification Form

If you are at least 21 years of age, and have completed one year of full-time service with an accredited college or university, you will be immediately eligible to enroll into the Baylor University Retirement Income Plan.

YOU WILL BE RESPONSIBLE FOR OBTAINING THE INFORMATION FROM YOUR FORMER EMPLOYER.

SERVICE ASSOCIATED WITH EARNING A DEGREE OR CERTIFICATION, SUCH AS A GRADUATE ASSISTANTSHIP, WORK STUDY, OR PRE-DOCTORAL SERVICE WILL NOT APPLY.

Name (please print): _____________________________ _______ ______________________________ First M.I. Last

Last 4-digits of Social Security Number: _____________________________________

⃝ I do not have prior university work experience.* Employee’s Initials _______ *If you do not have eligible prior university work experience, you may stop here and submit this form to HR.

SUBMIT THIS FORM TO THE BAYLOR UNIVERSITY HUMAN RESOURCES WITHIN 30 DAYS OF YOUR DATE OF HIRE. (Partial credit may be given for service from more than one organization. Submit one form per organization.)

The previous employer information below must be completed by the college or university in which the service credit was obtained.

Please indicate which best describes service type: ⃝ Full-Time Faculty (9+ hours / semester) ⃝ Part-time Faculty (less than 9 hours / semester) ⃝ Full-Time Staff (30+ hours / week) ⃝ Part-time Staff (less than 30 hours / week)

Name of Accredited College or University: _____________________________________________

Name of Accrediting Agency: _____________________________________________

Month / Year that Service Began: _____________ Month / Year that Service Ended: ________________

Total Length of Full-Time Service: _____ YEARS _____ MONTHS

Total Length of Part-Time Service: _____ YEARS _____ MONTHS ________ HOURS WORKED PER WEEK

Name of person completing this certification: _______________________________________________

Title of person completing this certification: _______________________________________________

Contact email: _________________________________________ Contact phone no.: _______________

Signature: ____________________________________________ Date: _________________________

Please fax or email this completed certification with letterhead coversheet to: FAX: 254.710.3819

OR EMAIL: askHR@baylor.edu

Please mail this completed certification to: Baylor University Human Resources One Bear Place #97053 Waco, TX 76798-7053

Questions about this form? askHR@baylor.edu or 254.710.2000 EPPR.3

Access Information Baylor Technology Login and Email Access

The Bear ID is a unique electronic identifier created for each student and employee of Baylor. It is used to access electronic resources like email, campus software installers, and some software systems, including Canvas, ClassRoll, and BaylorCompass. It also is considered a person's network ID. The Bear ID follow by "@baylor.edu" becomes an individual's Baylor email address.

Step 1. Activate your Bear ID and set your password. • As a new employee, you will receive a link and authorization code via an email message to your personal

email account. Use this link and code to gain access to the system and create yoursecurity questions.

• Be sure to choose questions you can answer consistently the same way, as answering thesequestions is one way to gain access to your account in case of a forgotten or expired password.

• After setting the security questions, you will enter a password to secure your account. Follow the directionsto choose a compliant password and enter your password in the two blanks provided. (NOTE: The passwordis case-sensitive.) If you do not receive an email from Baylor ITS to initiate your login setup, contact the ITSHelp Desk at 254-710-4357 (710-HELP).

For more information about your Bear ID, visit http://www.baylor.edu/its/index.php?id=40089. Baylor email accounts are reserved for use by current Baylor students and employees. For additional information, please reference Technology Systems Usage Policy BU-PP 025.

Step 2. Baylor DUO Passwords are becoming increasingly easy to compromise. They can often be stolen, guessed, and hacked -- you might not even know who else has your password and is accessing your account. Duo two-factor authentication adds a second layer of security to your account to make sure that it stays safe, even if someone else knows your password, by using your phone or other device to verify your identity.

To begin the enrollment process, please see the First-Time Enrollment Guide for device-specific installation instructions.

For more Information about DUO, visit http://www.baylor.edu/its/index.php?id=863033#q1 or, you can contact the ITS Help Desk at 254-710-4357 (710-HELP).

Baylor Online Directory Upon employment and after activating your Bear ID, review your online directory information and establish your personal release settings at https://www.baylor.edu/directory/.

Baylor Parking Services & ID Card Office After activating your Bear ID and setting up DUO, please review the guidelines and information required for parking on campus by choosing Faculty/Staff at www.baylor.edu/parking. Log in to your Parking Account using your Bear ID and password to officially register your vehicle(s) for campus access. Temporary Staff should review the Visitor parking information at www.baylor.edu/parking.

The ID card office is conveniently located with Parking Services. Present the ID Card and Parking Permit Authorization form to have your picture taken and ID card printed.

Office Hours: Monday – Thursday: 8 am - 5 pm. Friday: 8 am - 3:30 pm. Location: Speight Parking Garage, 1521 S. 4th Street. You may park in the visitor lot in front of Cashion Academic Center.

Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General InformationWhen key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employment based health coverage offered by Baylor University.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage

through the Marketplace begins in October each year for coverage starting January 1.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a

tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible

for a tax credit that lowers your monthly premium; or a reduction in certain cost-sharing if your employer does not offer

coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer

that would cover you (and not any other members of your family) is more than 9.5% of your household income for the

year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care

Act, you may be eligible for a tax credit.1 Baylor University’s health plan meets the “minimum value” standard set by

the Affordable Care Act.

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage (if eligible) offered by

Baylor University, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this

employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from

income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an

after-tax basis.

How Can I Get More Information?

For more information about your coverage offered by Baylor University, please check your summary plan description if

enrolled in the PPO plan, or your summary plan description if enrolled in the HDHP + HSA plan. You may also contact:

askHR@baylor.edu or askHR customer service center at ext. 2000.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986

PART B: Information About Health Coverage Offered by Your Employer This section contains information about health coverage offered by Baylor University. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. Contact askHR for information if needed.

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

As your employer, we offer a health plan to:o Full-time faculty, staff, and post-doctoral fellows appointed at .75 FTE or more per semester, full-

time regular staff (30 or more scheduled hours per week), and full-time temporary staff (30 or more

scheduled hours per week for a minimum of 90 days)

With respect to dependents, we offer coverage to eligible dependents who are:o An employee’s spouse

o An employee’s child who is:

Under 26 years of age or medically approved disabled prior to 26th birthday.

Child means:o Your natural child; or

o Your legally adopted child, including a child for whom the Participant is a party in a suit in which the

adoption of the child is sought; or

o Your stepchild; or

o Your foster child; or

o A child of your child who is your dependent for federal income tax purposes at the time application

of coverage of the child of your child is made; or

o A child for whom a Participant has received a court order requiring that Participant to have financial

responsibility for providing health insurance; or

o A child not listed above:

whose primary residence is your household; and

to whom you are legal guardian or related by blood or marriage; and who is dependent upon

you for more than one−half of his support as defined by the Internal Revenue Code of the

United States.

o Spouse means:

a person of the opposite sex to whom one is lawfully married, as defined by Article 1, Section 32

of the Texas Constitution, as the union of one man and one woman.

The Baylor University health coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process.